Unique Plan Description: NRS Neurosurg Lumbar Fusion, Post op EKM
Plan Selection Display: NRS Neurosurg Lumbar Fusion, Post op
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-11-04 18:20:18
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-12-09 09:53:43
Available at all facilities: Yes

NRS Neurosurg Lumbar Fusion, Post op EKM
Vital Signs
	Vital Signs
		Routine, Post-op
Activity
	Dangle
		T;N
			Comment: day of surgery
	Up in Chair
		T;N
			Comment: start afternoon/evening of surgery
	Ambulate
		T;N, With assistance, TID
	Activity-As Tolerated
		T;N
			Comment: ambulate with assistance
Diet
	NPO
		NPO Except for: Ice | Sips of Water
	Clear Liquid Diet
		Advance as Tolerated
Laboratory
Today's Lab
	Hemoglobin and Hematocrit
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
Tomorrow's Lab
	Hemoglobin and Hematocrit
		T+1;0400, Routine, DAILY, 3 Dose(s)/Time(s), spec type = Blood
	CBC with Diff
		T+3;0400, EVERY OTHER DAY, 14 Day(s), spec type = Blood
IV Solutions

	Sodium Chloride 0.9%
		1,000 mL, IV, 100 ml/hr
			Comment: Insert peripheral lock when tolerating fluids well
Medications
	Pepcid
		20 mg, Injection, IV PUSH, Q12H
			Comment: Change to oral famotidine when taking oral diet
		20 mg Tab BY MOUTH Q12H
	cyclobenzaprine
		5 mg, Tab, By Mouth, Q6H, PRN for spasms
	baclofen
		5 mg, Tab, By Mouth, Q6H, PRN for spasms
	diazePAM
		5 mg, Tab, BY MOUTH, Q6H, PRN for spasms
Patient Care
	Resuscitation Status
		Full Code
		No Code
	Notify MD of Lab results
		if Hgb <9 or HCT <25%
	Straight Catheter
		T;N, PRN, unable to void, Insert PRN symptomatic PVR > 300 mL or if asymptomatic > 500 mL
	VTE Advisor
		Neurosurgery - spinal
	Bladder Scan
		T;N, PRN, unable to void, Assess for residual
	Discontinue Urinary Catheter
		T+2;0600, Foley
	Cold Therapy
		Cooling pad, Incision, PRN, discomfort
			Comment: continuously, Polar Care
		Ice bag, Incision, PRN, discomfort
	Wound Drain
		Connect to compressed suction
			Comment: record outputs
	May Shower
		T;N, Beginning POD 2
	Dressing Care
		T;N, Maintain, Incisional negative pressure therapy dressing
	No NSAIDS (non steroidal anti-inflamatory)
		
	Incentive Spirometer
		Q1HAWAKE
Therapies
	Consult Physical Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Progressive Ambulation
			Comment: Reason to See: Evaluate and Treat, MD Verbatim: start post op day 1. Post op lumbar fusion
	Consult Occupational Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Evaluate and Treat
			Comment: Reason to See: Evaluate and Treat, MD Verbatim: start post op day 1. Post op lumbar fusion.

Oxygen Protocol
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID

Peripheral Lock - Access
Medications

	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

Pain Constipation Nausea Protocol </= to 65 EKM
Medications
		Select only one medication in each category(NOTE)*
Mild Pain
	acetaminophen
		650 mg, Tab, By Mouth, Q4H, PRN for see comment
			Comment: Discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient and/or temperature > 100.4F
		650 mg, Suppository, RECTALLY, Q6H, PRN for see comment
			Comment: Discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient and/or temperature > 100.4F
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN for pain-mild
			Comment: pain rating 1-3
		800 mg, Tab, By Mouth, Q8H, PRN for pain-mild
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-mild
			Comment: pain rating 1-3
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-mild
			Comment: Pain rating 1-3
	HYDROmorphone Injectable
		0.2 mg, Injection, IV Push, Q2H, PRN for pain-mild
			Comment: For pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN for pain-mild
			Comment: for pain rating 1-3 and if NPO
Moderate Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 7.5/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE-acetaminophen 10/325 mg oral tablet
		1 TAB, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	morphine  oral immediate release
		15 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: Pain rating 4-6
	HYDROmorphone Injectable
		0.2 mg, Injection, IV PUSH, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		0.4 mg, Injection, IV PUSH, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	morphine  IV
		2 mg, Syringe, IV Push, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		4 mg, Syringe, IV Push, Q2H, PRN for pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	ketorolac injectable
		15 mg, Injection, IV Push, Q6H, PRN for pain-moderate, duration: 48 hr
			Comment: For pain rating 4-6.
Severe Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 5/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 7.5/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE-acetaminophen 10/325 mg oral tablet
		2 TAB, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	oxyCODONE
		10 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: Pain rating 7-10
	HYDROmorphone Injectable
		0.4 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.5 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.6 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV PUSH, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		6 mg, Syringe, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN for see comment
			Comment: if patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
Constipation
	senna 8.6 mg oral tablet
		2 TAB, Tab, BY MOUTH, QHS
			Comment: Hold for diarrhea
	docusate
		100 mg, Capsule, By Mouth, DAILY
			Comment: Hold for diarrhea
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, Q12H, PRN, constipation
			Comment: Mix in 6 oz juice or water
		17 gm, Packet, By Mouth, DAILY, PRN, constipation
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
		30 mL, Suspension, By Mouth, Q12H, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
			Comment: If bisacodyl ineffective
	Enema-Administer
		Tap water, Q1H, constipation
			Comment: if suppository ineffective
Nausea Vomiting
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders(NOTE)*
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		6.25 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		12.5 mg, Injection, IM-Intramuscular, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds. Give as Deep IM Injection
		25 mg, Injection, IM-Intramuscular, Once, PRN for nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds. Give as Deep IM Injection
	Phenergan (JE)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	metoclopramide
		10 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN for nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	Notify MD
		If patient develops itching
		if no results from enema.

PCA hydromorphone (Dilaudid)
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, 20 ml/hr
			Comment: If no current IV fluid order.
Medications
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	Dilaudid Injectable
		0.5 mg, Injection, IV PUSH, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		Continuous Dose (mg/hr) 0 - 0.2 mg/hr, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 3 mg, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, PCA
			Comment: Adjust to patient's documented individual pain goal.  For continuous dosing, begin with no basal for mild/moderate pain; 0.1mg/hr for severe pain; adjust rate by 0.1mg/hr q30min up to a maximum of 0.2mg/hr as needed for moderate or severe pain (pain score>3) and down 0.1mg/hr q30 min as needed for mild or moderate.  DC basal rate if dose required is less than 0.1mg/hr (side effects present) and use patient controlled dosing only.  For patient controlled dose, start at 0.1mg for mild/moderate pain adjust by 0.1mg q30min up to a maximum of 0.2mg, For patient controlled dose, start at 0.2mg for severe pain and adjust by 0.1mg down q30 min as needed for mild or moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes, do not adjust both continuous or PCA dose at the same time (exception for comfort care patients)-  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		10 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	Dilaudid Injectable
		0.5 mg, Injection, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 3 mg, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, PCA
			Comment: STANDARD-NO BASAL.  .Adjust to patient's documented individual pain goal. Start patient controlled dose at 0.1mg for mild/moderate pain, and adjust by 0.1mg up to a maximum of 0.2mg or down q30min as needed for moderate or severe pain (pain score >3), Start patient controlled dose at 0.2mg for severe pain and adjust down by 0.1mg q30min as needed for mild/moderate pain.-  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		10 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	Dilaudid Injectable
		0.3 mg, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		Continuous Dose (mg/hr) No basal rate, Patient Admin Bolus (mg) 0.1 - 0.2 mg, Lockout Interval (min) = 15, 4-hour Limit (mg) 2 mg, Nurse Admin Bolus (mg) 0.2 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, PCA
			Comment: HIGH RISK PROTOCOL. Adjust to patient's documented individual pain goal. Start at 0.1mg and adjust by 0.1mg q30min to a maximum of 0.2mg as needed for moderate or severe pain (pain score >3). -  Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding,, and restart patient controlled dose at 0.1mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order
		10 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
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	Dilaudid Injectable
		1 mg, Injection, IV Push, Once, PRN, see comment, Routine, 2 hr
			Comment: May give as loading dose or if PCA pump not immediately available.
	HYDROmorphone 0.2 mg/mL PCA 50mL Standard IV
		Continuous Dose (mg/hr) 0.3 - 0.6 mg/hr, Patient Admin Bolus (mg) 0.1 - 0.5 mg, Lockout Interval (min) = 10, 4-hour Limit (mg) 4 mg, Nurse Admin Bolus (mg) 0.3 mg breakthrough pain, Nurse Admin Bolus Freq 1 hr, 50 mL, PCA IV, PCA
			Comment: OPIATE TOLERANT PROTOCOL. Adjust to patient's documented individual pain goal. Start at 0.3mg/hr and adjust dose by 0.1mg/hr up to a maximum of 0.6mg/hr q30min as needed for moderate or severe pain (pain score >3) and down by 0.1mg/hr q30min as needed for mild or moderate pain; Patient controlled dose start at 0.2mg and increase by 0.1mg q30min up to a maximum of 0.5mg as needed for moderate or severe pain (pain score >3) or decrease by 0.1mg q30min as needed for mild or moderate pain. Dose adjustment of EITHER the continuous or patient administered dose may occur every 30 minutes do not adjust both continuous or PCA dose at the same time (exception for comfort care patients) - Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR > or = 12bpm and normal depth, alert.  Consider oxygen protocol.  -  When decreasing or resuming PCA infusion after holding, discontinue basal if running, and decrease patient controlled dose at 0.2mg.-  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		10 mg, EVERY BAG
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: while on PCA
	Narcan
		0.1 mg, Injection, IV Push, Q5MIN, PRN, see comment
			Comment: Until desired response.  Follow with 10 mL NaCl Flush, for patients who are somnolent with minimal or no response to stimuli, RASS -3 to -5, or for respiratory rate less than or equal to 10/minute, notify physician while on PCA protocol.
Patient Care
	PCA Assessment
		T;N, Q15MIN, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+60, Q1H, 4, Dose(s)/Time(s)
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate. Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N+420, Q2H-Sch
			Comment: Assessment to include vital signs, pain, RASS, resp rate, resp pattern, pump settings, and ETCO2 if appropriate. Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N
			Comment: ongoing, with any patient controlled dose, basal rate change or nurse administered bolus. Assessment to include vital signs, pain, RASS, resp rate, resp pattern and pump settings. If resp rate <10, or SBP <90 reassess patient q15min x4, then q1h x4, then q2h.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < 10 or systolic BP < 90
		T;N
	Notify MD
		T;N, if patient is on benzodiazepines (lorazepam, midazolam, diazepam etc.)
		T;N, if respirations </= 10, or  systolic BP < 90.
		T;N, if pain increases or unable to wean in 12 hr
		T;N, if ETCO2 greater than 50
	PCA Parameters
		T;N
			Comment: Stop PCA for 1 hour if patient develops respiratory depression (respiratory quality is shallow, respiratory rate is < or = 12 bpm), RASS -2, patient is lethargic, frequently drowsy or drifts off to sleep during conversation.  Do not resume PCA unless RASS 0 to -1, RR < or = 12bpm and normal depth, alert.  Consider oxygen protocol.  Discontinue PCA & protocol if patient somnolent with minimal or no response to stimuli or respiratory rate < or = 10 or RASS -3 to -5  and/or systolic blood pressure < 90mm Hg.  Do not resume PCA without MD order.
		T;N
			Comment: Do not initiate any PCA (continuous or patient administered doses) in patients with sleep apnea (OSA) without verbal verification from physician.  Basal (continuous) PCA dosing should not be used for patients with history of sleep apnea (OSA), or respiratory problems (lung disease, heart failure). Do not use patient controlled doses of PCA unless patient is fully able to understand and comply with instruction -this includes restricting use for patients with dementia, delirium, confusion. Start dosing at the lowest range possible for continuous and patient administered doses (exceptions comfort care patients, oncology patients routinely receiving opiates, chronic pain patient routinely receiving opiates), including starting with no basal rate.
	PCA weaning parameters
		T;N
			Comment: 1.  Administer oral opiate.2.  Provide patient education on weaning process3.  If a basal (continuous) rate is running, turn it off upon administration of oral opiate4.  Begin demand (patient controlled dose) wean 4hr after initial opiate dose.  Every 4hr decrease demand dose by 50% until adequate pain control is achieved (defined as a pain scale of <4 or meeting patient's goal for pain control).  Do not decrease demand below minimum dose in PCA protocol for patient controlled dosing (0.5mg morphine, 0.1mg hydromorphone)5.  If patient does not use demand dose in at least 4hr after receiving oral medication, discontinue PCA.6.  Notify MD if pain increases or unable to wean in 12hr.
Therapies
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: RT, while on PCA

Pain Constipation Nausea Protocol > 65 Geriatric E
Medications
		Select only one medication in each category(NOTE)*
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H-Sch, T;N
			Comment: Consider IV Acetaminophen (Ofirmev) if NPO.
Mild Pain
	acetaminophen
		1,000 mg, Tab, By Mouth, Q8H, PRN pain-mild
			Comment: For pain rating 1-3 or temp >100.4; Consider IV Acetaminophen (Ofirmev) if NPO.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, PRN pain-mild
			Comment: For pain rating 1-3 or temp >100.4.
	ibuprofen
		400 mg, Tab, By Mouth, Q8H, PRN pain-mild
			Comment: For pain rating 1-3, do not use in patients with CrCl < 50mL/min and/or SBP< 90
Moderate Pain
	oxyCODONE
		2.5 mg, Tab, By Mouth, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6
	HYDROmorphone Injectable
		0.2 mg, Injection, IV Push, Q4H, PRN pain-moderate
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics.
	Journavx
		100 mg, Tab, By Mouth, Once
		50 mg, Tab, By Mouth, BID, duration: 48 hr
Severe Pain
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN pain-severe
			Comment: For pain rating 7-10.
	HYDROmorphone Injectable
		0.4 mg, Injection, IV Push, Q2H, PRN pain-severe
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics.
		Opiate Reversal(NOTE)*
	Narcan
		0.2 mg, Injection, IV Push, Q2MIN, PRN see comment
			Comment: If patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 10 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.  May give 0.2mg every 2 min up to 1mg total dose.
PRN Discomfort
	trolamine salicylate 10% topical cream
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	menthol-methyl salicylate topical
		1 appl, Cream, TOPICAL, TID, PRN discomfort
			Comment: Apply to affected area.
	lidocaine 4% topical patch
		1 patch, Patch, TransDERMAL, DAILY
	lidocaine Patch Removal
		Patch Removal, Patch, TransDERMAL, QHS
	Medication patch site check
		T;N+720, Q12H
Constipation
	senna 8.6 mg oral tablet
		1 TAB, Tab, By Mouth, BID, PRN constipation
			Comment: Hold for loose stools, if PRN miralax is ordered and ineffective, okay to give senna
		1 TAB, Tab, By Mouth, BID
			Comment: Hold for loose stools
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, DAILY
			Comment: Hold for loose stools.  Mix in 6oz juice or water.
		17 gm, Packet, By Mouth, DAILY, PRN constipation
			Comment: Hold for loose stools.  Mix in 6oz juice or water. If PRN senna also ordered, prioritize miralax
	Dulcolax
		10 mg, Suppository, RECTALLY, Q12H, PRN constipation
			Comment: If other agents ineffective or if patient NPO.
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN constipation
			Comment: If suppository ineffective.
	Enema-Administer
		Tap water, Q1H, PRN, see comment
			Comment: If suppository ineffective.
Nausea Vomiting
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN nausea and/or vomiting
			Comment: If unable to take by mouth.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase